More than 1,400 residents in 55 internal medicine residency programs were surveyed by the American Board of Internal Medicine about the adequacy of their training in end-of-life care (reported in Foley, 1997). The percentage of residents reporting “adequate training” in specific areas was
72 percent, managing pain and other symptoms;
62 percent, telling patients that they are dying;
38 percent, describing what the dying process will be like; and
32 percent, talking to patients who request assistance in dying.
Most new physicians leave medical school and residency programs with little training or experience in caring for dying patients. In most cases, a few lectures are folded into other courses (in many cases in psychiatry and behavioral sciences, ethics, or the humanities). A few schools offer full-length courses on end-of-life care, but they are nearly all electives. According to the limited information available, most end-of-life training is provided in lectures only. Contact with dying patients, particularly for undergraduate medical students, if any, is limited.
Formal curriculum in end-of-life care is presented predominantly in preclinical years. In clinical training, which tends to be more informal and less systematic, teachers may have no special interest or expertise in end-of-life care. The importance of role models and mentors who are enthusiastic about caring for dying patients has largely been overlooked.
There is a tremendous opportunity to train the next generation of physicians in the care of dying patients. At the same time, opportunities must be created to improve the competence of physicians who are already practicing, but who have had inadequate preparation in end-of-life care.
Textbooks play an important role both in educating medical students and in informing practicing physicians of the standard of care for each disease covered. The topics included in textbooks and the way information is organized may be strong influences on the practice of medicine. In the past few years, researchers have looked systematically at the information relating to end-of-life issues that is contained in a variety of medical textbooks. Two landmark studies, one of general medical texts and the other of medical specialty texts, which are the most recent and comprehensive, are presented here (a similar analysis of nursing texts is discussed later in this chapter). Both studies included specific cancers in their analyses.